The United States spent $226.7 billion on smoking-related healthcare per year in 2014 [1]. $125.7 billion of those costs were covered by Medicare or Medicaid [1]. In other words, over 50% of smoking-related healthcare costs were funded by taxpayer money –whether those taxpayers smoke or not [1]. Should nonsmokers be responsible for the healthcare of smokers? The ethical framework luck egalitarianism states that any inequality between two individuals should be neutralized unless that inequality arises from a free choice made by one individual [2]. Thus, those who freely choose not to smoke should not be responsible for the healthcare of those who freely do. The logic seems simple enough; however, I argue that this framework should not serve as the basis of healthcare policy.
In the following paragraphs, I will first articulate the luck egalitarianism framework, with particular attention to the concepts of voluntary choice and moral neutrality. I will demonstrate how this framework might be applied to health policy. I will then argue that, at a deeper examination, the luck egalitarianism framework is impractical in two ways. (1) The identification of the point at which one individual’s lifestyle choice is free and voluntary is arbitrary [3]. If we cannot precisely identify free choice, we cannot precisely identify inequality. (2) The reasoning used to determine, out of all ‘imprudent’ free choices, which are deserving of an individual’s unequal treatment is arbitrary [4]. We cannot determine which inequalities to treat unequally without making moral, arbitrary judgments about an individual’s lifestyle [4]. For these reasons, I will argue that luck egalitarianism does not serve as a pragmatic healthcare policy framework. Thus, smokers and others responsible for their poor health outcomes should be entitled to equal healthcare assistance.
The luck egalitarianism framework.
Theorists Joar Björk et al. present a principled view of luck egalitarianism that aims to avoid moral judgment of an individual’s lifestyle via an infringement argument. Luck egalitarianism states that inequalities between individual X and individual Y should be neutralized unless, say, X makes a choice that holds them responsible for the development of inequality [2]. Luck egalitarianism is not meant to punish nor morally judge the lifestyle choice of X, and, thus, seeks to be morally neutral [4]. Instead, the lifestyle choice of X only becomes ‘imprudent’ if it negatively infringes upon individual Y, who has made different choices and who lives a lifestyle that is different from, or unequal to that of X [2]. Björk et al. connect free choice directly to infringement.
Individual X infringes on the lifestyle of individual Y by freely choosing to consume common resources [2]. These resources would otherwise be available to Y [2]. To perform this infringement, X must satisfy the following conditions:
I. X’s choice must lead to a high risk of common resource consumption [2].
II. X’s choice must risk significant common resource consumption [2].
III. X must be able to easily avoid this choice [2].
IV. X must be aware that their choice leads to a high risk of significant resource consumption and is avoidable [2].
Conditions I-IV offer principles by which one can hold an individual personally responsible for their choice without claiming the individual’s lifestyle to be morally good or bad. Note that conditions I-IV hinge upon whether an individual has consumed beyond a previously defined maximum of common resource use, not whether their choice is valued by society. If luck egalitarianism were to exempt holding personal responsibility against individuals whose choices of significant resource consumption benefit society, then we would constantly have to determine which choices really do benefit society [4]. This would destroy the moral neutrality—or avoidance of moral judgment—that luck egalitarianism seeks to uphold [4].
Luck egalitarianism discriminates between the individual who chooses to smoke and the individual who chooses not to smoke. Assume that it is widely known that smoking is a leading risk factor for lung cancer [4]. Moreover, lung cancer treatment draws upon a pool of common healthcare resources [4]. These healthcare resources are finite [4]. It is known that treating the lung cancer of one individual may use significant resources and deprive equal lung cancer treatment to other individuals [4]. It is possible for a nonsmoker to develop lung cancer.
Individuals who choose to smoke do so knowing that they risk development of lung cancer, and by extension, deprive individuals who choose not to smoke of healthcare resources for lung cancer treatment [4]. A policy in which nonsmokers are prioritized over smokers in lung cancer treatment can address this situation [2]. In this policy, smokers and nonsmokers are recognized as unequal groups due to the smokers’ free choice to smoke. Smokers and nonsmokers are treated unequally in accordance.
Objection to the luck egalitarianism framework.
In theory, the above healthcare policy seems relatively just. However, in practice, healthcare policies founded on luck egalitarianism encounter the following issues:
I. How can we be certain that an individual’s imprudent choice was made freely?
II. How can we determine, out of all possible imprudent choices, which should cause the individual to be treated unequally?
I will first address Question I. An individual’s independent choice to light a cigarette and smoke seems evidence enough for free choice assuming that the following conditions are satisfied. The individual understands that smoking may lead to significant healthcare costs. The individual is not physically coerced to smoke by another individual, and can, therefore, avoid smoking.
However, philosopher Daniel Wikler questions to what extent lifestyle choices are truly free. Individuals are subject to falling into automatic and thoughtless habit [3]. Many of these habits are learned from an individual’s mentors, peers, or environment [3]. So the individual who chooses to smoke may not have done so by their own accord, but instead because they were indoctrinated from birth into a culture that promotes smoking as a social custom.
Additionally, assume that an individual makes a truly free choice to smoke one cigarette. Assume that smoking one cigarette alone will not cause lung cancer. Even smoking a few cigarettes alone will not cause lung cancer. However, the individual happens to have a mutation on an allele that increases susceptibility to nicotine addiction and the individual falls into the mindless habit of smoking several packs of cigarettes a day. We are certain that the individual’s development of lung cancer is due to their developed habit of copious smoking. Can we truly say that the individual’s later actions of smoking, which caused lung cancer, were freely chosen [3]? The individual is subordinated to the disease of addiction and their decision-making is hindered [3].
The above arguments demonstrate that we cannot be certain that an individual’s choice to smoke is free and voluntary. If we are not certain that an individual’s choice to smoke is voluntary, then we cannot hold that individual responsible for their poor health. Thus, we cannot treat a smoker and nonsmoker unequally because that inequality is not founded in free choice.
Moreover, smoking contributes to lung cancer along with several other risk factors, such as genetics and air pollutants [2, 5]. Even if an individual’s choice to smoke is free and voluntary, we cannot be certain that smoking was the actual cause of their development of lung cancer [2]. By luck egalitarianism, we cannot hold an individual personally responsible for a health condition that was unrelated to their free choices. This leads to the same conclusion: we cannot treat a smoker and nonsmoker unequally because that inequality is not founded in free choice. Thus, healthcare policy cannot deprioritize smokers in lung cancer treatment. Individuals who may (or may not) be personally responsible for their poor health should be entitled to equal healthcare.
I will now address Question II. By Björk et al., an individual’s choice is imprudent if the individual is aware that their choice leads to a high risk of significant consumption of common resources and if that choice is easily avoidable [2]. I argue that this definition of an imprudent choice claims not to be a moral judgment of lifestyle [4]. However, luck egalitarianism’s moral neutrality makes it difficult to determine which imprudent choices should cause an individual to be treated unequally.
Philosopher Stephen Wilkinson presents the reverse restoration argument, which can be written in terms of Björk et al.’s luck egalitarianism framework. This argument assumes it to be widely known that smokers die earlier [4]. In the United States, “life expectancy for smokers is at least 10 years shorter than for nonsmokers” [6]. This argument also assumes that living into old age can increase healthcare need and consequently incur significant health costs [4]. In the United States, senior care for one individual can cost $72,000 per year [7].
It is likely that costs associated with old age for one individual cumulatively account for more healthcare spending than costs associated with a smoker who dies young [4]. Nonsmokers can freely choose not to smoke. Their choice is avoidable, and they understand that by increasing the likelihood that they will live into old age, they risk significant consumption of common resources [4]. Thus, an individual’s choice not to smoke can be classified as imprudent. It can be equally claimed that those who choose not to smoke deprive smokers of healthcare resources [4]. Because nonsmokers’ free choice against smoking creates inequality, nonsmokers should be treated unequally [4].
The above argument shows that luck egalitarianism can be reversed in a way that is not likely to be accepted by healthcare policymakers [4]. It seems as though we must be able to select between ‘imprudent choices’ that should cause an individual to be treated unequally and those that should not.
Wilkinson recognizes that this selection can be attempted via consideration of social value [4]. A society may value not smoking since not smoking is largely beneficial to society (no secondhand smoke) while it may not value smoking [4]. Therefore, individuals who choose not to smoke would be prioritized in healthcare such as lung cancer treatment. Moreover, if choosing between treatment of a smoker who is a parent and a smoker who is not a parent, because parenting benefits society, the parent who smokes would be treated first [4]. This type of value judgment begins to morally examine an individual’s lifestyle rather than the apparent consequences of their free choices [4]. Furthermore, social values fluctuate, and moral judgment of an individual’s lifestyle would be based on an arbitrary criterion [4]. Such judgment contradicts luck egalitarianism’s commitment to moral neutrality [4].
Even if consideration of social values did not threaten the commitment to moral neutrality, positioning healthcare workers as moral police limits free choice. If all individuals answered to the moral police, free choice would be eradicated, and luck egalitarianism as a framework becomes irrelevant. Thus, luck egalitarianism does not serve as a practical healthcare policy framework. Those who may or may not be personally responsible for their poor health should be entitled to equal healthcare.
Luck egalitarianism holds that individuals who are personally responsible for their poor health should not be entitled to healthcare equal to that of individuals who are not personally responsible for their poor health [2]. An individual’s personal responsibility is determined by their free choice and awareness that their choice risks significant consumption of common resources and is easily avoidable [2]. Luck egalitarianism aims not to judge lifestyle choices, but to measure when an individual’s free choice might infringe upon another’s ability to benefit from common resources [2]. However, when applied to healthcare policy, luck egalitarianism cannot, with certainty, identify a choice as free [3]. It also cannot determine which choices should lead to unequal treatment without morally judging lifestyle [4]. Thus, smokers and others deemed personally responsible for their poor health should be entitled to equal healthcare assistance.
References:
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